________ Your office information is correctproofer’s initialshere

________ Appointment & Patient information is correctproofer’s initialshere

________ Procedures & Diagrams are correctproofer’s initialshere

NON-PERSONALIZEDREFERRAL SLIPSFRONT IMPRINT

David C. Miller, DDS1031 Founders Row • Greensboro, GA 30642

Tel 706.454.1500 • Fax 706.454.1501 • www.oconeeoralsurgery.com

Today’s Date:

Patient’s Name:

Referred By:

Referring Doctor’s Tel. #:

ADDITIONAL INFORMATION:

ORAL SURGERY EVALUATION❏ Exodontia - (Please Indicate Teeth Below)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

32 31 30 29 28 27 2625 242322 21 20 19 18 17

A B C D E F G H I JON M L KT S R Q P

IMPLANT EVALUATION

❏ IMPLANT #:

❏ IMPLANT BRAND:

❏ SURGICAL TEMPLATE:❏ Will Be Provided ❏ Not Necessary

❏ BONE GRAFTING/AUGMENTATION:

❏ SOFT TISSUE ENHANCEMENT:

ADDITIONAL INFORMATION:

Please visit our website at www.oconeeoralsurgery.comto pre-register and for additional information about our office

David C. Miller, DDS

1031 Founders RowGreensboro, GA 30642

Tel 706.454.1500Fax 706.454.1501

www.oconeeoralsurgery.com

Publix

Madison

Hwy. 44

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Atlanta Augusta

Greensboro

Eatonton

Exit 130

Lake OconeeOral Surgery &

Dental Implant Center1031 Founders Row

706-454-1500

I-20

Linger Longer Rd.

________ Map R

edraws all correct (if applicable)

proofer’s initialshere

________ Spelling/P

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proofer’s initialsLocations are correct

here

________ Nam

e(s), Address(es), P

hone(s) proofer’s initials

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